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medicine for finals > OSCE > Flashcards

OSCE Flashcards

1
Q

aortic stenosis: causes

A

congenital - bicuspid valve
acquired - senile calcification, rheumatic fever

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2
Q

aortic stenosis: differential for an systolic murmur

A

HOCM
VSD
aortic sclerosis
flow murmur
coarctation of the aorta

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3
Q

aortic stenosis: examination findings

A

ejection systolic murmur heart loudest in aortic area and radiating to the carotids

soft S2
slow rising pulse
narrow pulse pressure
displaced apex

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4
Q

aortic stenosis: presenting features

A

asymptomatic
dyspnoea
syncope

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5
Q

aortic stenosis: management

A

monitoring

medical management of HF

if severe or symptomatic, TAVR or surgery

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6
Q

aortic stenosis: investigations

A

Echo
ECG
CXR

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7
Q

mitral stenosis: presenting features

A

asymptomatic
dyspnoea
haemoptysis
malar flush
palpitations (AF)

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8
Q

mitral stenosis: causes

A

acquired - rheumatic fever

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9
Q

mitral stenosis: examination findings

A

Mid-diastolic murmur heard loudest at the apex, reinforced by leaning on side in expiration

loud S1
malar flush
irregular pulse (due to AF)
evidence of pulmonary hypertension (P mitrale)

signs of rheumatic fever (rash, nodules etc.)

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10
Q

mitral stenosis: differential for diastolic murmur

A

Austin-Flint murmur
Large mitral valve leaflet from endocarditis or myxoma (late diastolic murmur with mitral ‘plop’)

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11
Q

mitral stenosis: investigations

A

Echo
ECG
CXR

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12
Q

mitral stenosis: management

A

medical management of AF and heart failure

if severe or symptomatic, mitral valvuloplasty or surgery

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13
Q

mitral stenosis: complications

A

pulmonary HTN
AF

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14
Q

Duke’s Major Criteria for Endocarditis

A
  • typical organism found on two blood cultures
  • evidence of endocardial involvement (Echo)

2 = diagnostic

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15
Q

Duke’s Minor Criteria for Endocarditis

A
  • fever >38deg
  • suggestive features on echo
  • predisposition (e.g. prosthetic valve, IVDU)
  • embolic phenomena (Janeway Lesions, clubbing, splinter haemorrhages)
  • immunological phenomenon (Roth spots, Osler nodes, vasculitis)
  • atypical organisms on blood culture

5 or 1 major + 3 minor = diagnostic

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16
Q

Infective endocarditis: empiric antibiotics for native valve disease

A

amoxicillin + gentamicin

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17
Q

Duckett Jones Major Criteria for Rheumatoid Fever

A
  • arthritis
  • (peri)carditis
  • Sydenham’s chorea
  • Rheumatoid nodules
  • Erythema marginatum

2 = diagnostic

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18
Q

Duckett Jones Minor Criteria for Rheumatoid Fever

A
  • fever
  • arthralgia (not arthritis)
  • recent Strep infection (culture or raised ASOT)
  • raised inflammatory markers
  • ECG changes (QT or PR prolongation)

1 major + 2 minor = diagnostic

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19
Q

Rheumatoid Fever: management

A
  • bed rest
  • high dose aspirin
  • penicillin (benzylpenicillin IV STAT + phenoxymethylpenicillin PO 10 days)
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20
Q

mitral regurgitation: causes

A

congenital - connective tissue disease
acquired - degeneration/prolapse, infective endocarditis, rheumatic fever, MI (papillary muscle rupture), dilated cardiomyopathy (annular dilatation), infiltrative (amyloid)

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21
Q

mitral regurgitation: examination findings

A

pan systolic murmur heard loudest at the apex and radiating to the axilla

soft S1, split S2
pulmonary oedema
LV dilatation

signs of endocarditis

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22
Q

mitral regurgitation: presenting features

A

asymptomatic
fatigue
dyspnoea
oedema
palpitations (AF)

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23
Q

mitral regurgitation: investigations

A

Echo
ECG
CXR

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24
Q

mitral regurgitation: management

A

medical management of AF and HF

for severe for symptomatic disease, surgical repair (occasionally consider mitral clip)

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25
Q

aortic regurgitation: causes

A

congenital - bicuspid valve
acquired - infective endocarditis, rheumatic fever, aortic root dissection, aortitis (syphillis, AS)

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26
Q

aortic regurgitation: presenting features

A

asymptomatic

dyspnoea, worse on lying flat

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27
Q

aortic regurgitation: examination findings

A

early diastolic murmur heart at LLSE, reinforced by leaning forward in expiration

+/- Austin Flint Murmur

collapsing / waterhammer pulse
wide pulse pressure
hyperkinetic, displaced apex beat
S3

Quincke’s sign (nailbed capillary pulsation)
De Musset’s sign (head bobbing)

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28
Q

aortic regurgitation: investigations

A

Echo
ECG
CXR

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29
Q

aortic regurgitation: management

A

monitoring

medical management of heart failure

for severe or symptomatic disease, aortic valve replacement

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30
Q

tricuspid regurgitation: causes

A

congenital - Ebstein’s Anomaly
acquired - pulmonary HTN (e.g. COPD), rheumatic fever, infective endocarditis (IVDU), carcinoid

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31
Q

tricuspid regurgitation: presenting features

A

asymptomatic

fatigue
dyspnoea
palpitations (AF)
epigastric pain, jaundice, ascites

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32
Q

tricuspid regurgitation: examination findings

A

pan-systolic murmur, reinforced by inspiration

raised JVP with systolic waves (V waves)
pulsative liver
ascites
peripheral oedema
pulmonary hypertension
RV heave
split S2

33
Q

tricuspid regurgitation: investigations

A

Echo
ECG
CXR

34
Q

tricuspid regurgitation: management

A

monitoring

medical management of AF, HF and oedema

for severe or refractory disease, valve repair or annuloplasty

35
Q

tricuspid regurgitation: management

A

monitoring

medical management of AF, HF and oedema

for severe or refractory disease, valve repair or annuloplasty

36
Q

pulmonary fibrosis: examination findings

A
  • clubbing
  • fine end-inspiratory crackles

signs of autoimmune disease (e.g. RA, SLE, sclerosis) or drug treatments (Cushingoid, slate-grey from amiodarone)

37
Q

pulmonary fibrosis: causes (by distribution)

A

Upper Zone = CHARTS
- coal worker’s pneumoconiosis
- hypersensitivity pneumonitis
- ankylosing spondylitis
- radiation
- TB
- silicosis and sarcoidosis

Lower Zone = STAIR
- SLE
- toxins (amiodarone, methotrexate, nitrofurantoin)
- asbestos
- idiopathic pulmonary fibrosis
- rheumatoid

38
Q

pulmonary fibrosis: causes (general approach)

A
  • idiopathic
  • iatrogenic (amiodarone, methotrexate, nitrofurantoin, radiation)
  • inflammatory (RA, SLE, AS)
  • infection (TB)
  • industrial (allergic hypersensitivity pneumonitis, asbestosis, coal workers pneumoconiosis)
39
Q

pulmonary fibrosis: investigations

A
  • bloods (ESR, RF/anti-CCP, ANA/anti-dsDNA)
  • ABG (evidence of respiratory failure)
  • CXR
  • Spirometry
  • High resolution CT scan
  • BAL (rule-out infection)
40
Q

pulmonary fibrosis: management

A

Vaccination, smoking cessation and pulmonary rehabilitation

Also,
- avoid triggers
- immunosuppression if ?inflammatory
- antifibrotic

Lung transplant in end-stage

41
Q

wheeze: causes

A
  • asthma
  • COPD
  • bronchiectasis
  • other airway obstruction (foreign body, external compression)
42
Q

asthma: examination findings

A

may be normal!

  • expiratory polyphonic wheeze
  • cough
  • ‘tight chest’ and hyperventilation
  • atopic features
43
Q

COPD: examination findings

A
  • nebulizers / inhalers / sputum pot
  • central cyanosis
  • pursed lips, tripoding, accessory muscles
  • tar-staining
  • CO2 retention flap
  • hyperexpanded chest
  • hyper-resonant percussion note
  • expiratory polyphonic wheeze
  • crackles (consolidation)
  • cough
  • cor pulmonale (RV heave, oedema, raised JVP)
44
Q

COPD: investigations

A
  • bloods (FBC, CRP)
  • ABG
  • CXR
  • ECG
  • spirometry (FEV1:FVC diagnostic, FEV1 prognostic)
  • alpha 1 anti-trypsin levels (young patient)
45
Q

COPD: management

A

Vaccination, smoking cessation, pulmonary rehabilitation

Routine management involves SABA/SAMA first-line, escalate to LABA+ICS (asthmatic features) or LABA+LAMA

Treat acute exacerbations with antibiotics, oral steroids

End-stage interventions are NIV/BIPAP (in exacerbations), LTOT (if stopped smoking)

46
Q

COPD: complications

A

acute/infective exacerbations
cor pulmonale
secondary pneumothorax
secondary polycythaemia
adrenal insufficiency (due to steroid use)

47
Q

asthma: investigations

A
  • ABG
  • ECG
  • CXR
  • spirometry with bronchodilator reversibility
  • FeNO
48
Q

asthma: management (routine)

A

Follow NICE/BTS Guidelines
1. SABA
2. SABA/ICS MART
3. Add LABA/LAMA, step-up ICS
4. Consider LTRA

49
Q

asthma: management (acute exacerbation)

A

Admit life-threatening asthma
Serial peak flow and ABG
O2 (aim SaO2 94%)
Bronchodilator (back-to-back nebulizer or inhaler)
Oral steroids
IV magnesium sulfate, aminophylline, adrenaline

Aim 24hrs on home medications prior to discharge

50
Q

bronchiectasis: examination findings

A
  • cachexia
  • clubbing
  • mixed character crackles which alter with coughing
  • wheeze
  • cough
  • cor pulmonale
51
Q

bronchiectasis: examination findings

A
  • sputum pot
  • cachexia
  • clubbing
  • tachypnoea
  • mixed character crackles which alter with coughing
  • wheeze
  • cor pulmonale (RV heave, oedema, raised JVP)
52
Q

bronchiectasis: causes

A
  • idiopathic
  • impaired mucociliary clearance (CF, Kartagener’s syndrome, immunoglobulin deficiency)
  • infection (TB, Whooping Cough, Measles, severe pneumonia)
  • inflammatory (RA)
  • immunodeficiency (HIV, CLL)
53
Q

bronchiectasis: investigations

A
  • bloods (FBC, CRP, cultures)
  • ECG
  • CXR
  • sputum culture (Haemophilus)
  • spirometry (obstructive pattern)
  • High resolution CT (honeycombing)

consider chloride sweat test (CF), immunoglobulin studies, mucociliary clearance study

54
Q

bronchiectasis: management

A

Vaccination, smoking cessation, pulmonary rehabilitation

Treat infective exacerbations aggressive
Inhaled corticosteroids
Bronchodilators

55
Q

bronchiectasis: most likely pathogen and empiric antibiotic for infective exacerbations

A

Haemophilus
In CF –> pseudomonas

Ciprofloxacin first-line (covers pseudomonas)

56
Q

pneumonia: examination findings

A
  • sputum pot (rusty –> pneumococcus)
  • tachypnoea, dyspnoea
  • reduced expansion
  • dull percussion note
  • coarse crackles
  • increased vocal resonance/fremitus (tactile –> empyema)
  • bronchial breathing
57
Q

pleural effusion: examination findings

A
  • tachypnoea, dyspnoea
  • tracheal deviation (away from effusion)
  • reduced expansion
  • stony dull percussion note
  • reduced vocal resonance/fremitus
  • reduced breath sounds
58
Q

pneumonia: investigations

A
  • ABG
  • bloods (FBC, CRP, urea, serology and cultures)
  • CXR
  • sputum culture
  • urinary antigens
59
Q

pleural effusion: causes

A
  • cancer
  • congestive cardiac failure
  • liver failure
  • renal failure
  • connective tissue disease (RA, SLE)
60
Q

pleural effusion: investigations

A
  • ABG
  • bloods (FBC, CRP, U&Es, LFTs, cultures)
  • pleural aspirate (biochemistry including protein, LDH –> Light’s Criteria) +/- drainage
61
Q

epigastric pain: causes

A
  • dyspepsia
  • peptic ulcer (+/- perforated)
  • pancreatitis
62
Q

RUQ pain: causes

A
  • perforated ulcer
  • gallstones
  • hepatitis
  • abscess (hepatic, subphrenic)
  • retrocaecal appendix
  • hepatic flexure tumour
  • pyelonephritis
63
Q

LUQ pain: causes

A
  • splenic rupture or infarction
  • abscess (splenic, subphrenic)
  • splenic flexure tumour
  • pyelonephritis
64
Q

RLQ pain: causes

A
  • appendicitis
  • diverticulitis
  • colitis (infectious, ischaemia, inflammatory)
  • UTI or pyelonephritis
  • ovarian cyst or torsion
65
Q

LLQ pain: causes

A
  • diverticulitis
  • colitis (infectious, ischaemia, inflammatory)
  • UTI or pyelonephritis
  • ovarian cyst or torsion
66
Q

diffuse abdominal pain: causes

A
  • perforation
  • obstruction
  • mesenteric ischaemia
  • pancreatitis
  • ruptured AAA
  • incarcerated hernia
  • UTI
  • gynaecological (ruptured ectopic, ovarian pathology, fibroids or endometriosis)
67
Q

acute abdomen: investigations

A
  • urine dip and pregnancy test
  • VBG (lactate)
  • bloods (FBC, CRP, cultures, LFT, amylase, U&E)
  • imaging (CT > AXR)
68
Q

acute abdomen: management

A
  • A-E assessment (fluids, O2)
  • Analgesia
  • Preparation for theatre (NBM, fluids, catheter, Abx, G&S)
69
Q

hepatomegaly: examination findings

A
  • RUQ mass, moves on inspiration, dull to percuss
  • cachexia
  • jaundice (scleral icterus, excoriations)
  • leukonychia, Clubbing
  • Dupytren’s contracture, palmar erythema
  • xanthelasma
  • parotid swelling, fetor hepaticus
  • ascites
  • spider naevi, caput medusae
  • gynaecomastia, reduced body hair
  • asterixis
  • encephalopathy (altered consciousness)

consider underlying causes: needle tract marks, slate-grey pigmentation (hemochromatosis), signs of HF, cachexia (HCC)

70
Q

hepatomegaly: causes

A
  • cirrhosis
  • carcinoma (HCC, secondaries)
  • congestive heart failure

also
- infection (Hep B, C)
- immune (PBC, PSC, autoimmune hepatitis)
- infiltrative (amyloid, myeloproliferative disease)
- PKD

71
Q

hepatomegaly: investigations

A
  • routine bloods (FBC, clotting, U&Es, LFT, glucose)
  • ‘liver screen’ (pANCA, AMA, anti-SMA, anti-LMK1, HBV/HCV serology, ferritin, caeruloplasmin, A1AT, AFP)
  • synthetic functions (INR, albumin, platelets)
  • USS abdomen
  • Ascitic tap
  • ERCP (?PSC)
72
Q

splenomegaly: examination findings

A
  • RUQ mass, moves on inspiration
  • anaemia
  • lymphadenopathy
  • purpura
  • hepatomegaly
73
Q

splenomegaly: causes

A

MASSIVE:
- myeloproliferative disorders (CML, myelofibrosis)
- infections (malaria, leishmaniasis)

MODERATE or TIP:
- myelo/lymphoproliferative disorders
- infiltration (amyloidosis)
- portal HTN
- infection (EBV, IE, hepatitis)
- haemolytic anaemia

74
Q

splenomegaly: investigations

A
  • bloods (FBC, blood film including thin and thick for malaria, viral serology)
  • USS first-line, consider CT
  • BM aspirate
  • LN biopsy
75
Q

splenectomy: indications

A

rupture (trauma)
haematological (ITP, hereditary spherocytosis)

76
Q

splenectomy: work up

A

Pneumococcus, Meningococcus and Haemophilus vaccination (ideally 2 weeks prior)

Life-long penicillin prophylaxis

Medical alert bracelet

77
Q

renal enlargement: causes (uni- and bilateral)

A

UNILATERAL
- PKD
- RCC
- simple cyst
- hydronephrosis (ureteric obstruction)

BILATERAL
- PKD
- bilateral RCC
- hydronephrosis (urethral or bladder obstruction)
- tuberous sclerosis (renal angiomyolipoma)
- amyloidosis

78
Q

renal enlargement: investigations

A
  • urine dip and MC&S
  • bloods (U&Es)
  • USS abdomen +/- biopsy
  • CT non-contrast (stones) or urogram (malignancy)
  • genetic studies (ADPKD1 or 2)

medicine for finals (10 decks)

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